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General NPI Number Information
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NPI Number | 1669864658
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Entity Type | Organization
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Legal Business Name | PRIME RADIOLOGY OF WINTER HAVEN, INC.
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Dates
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Enumeration Date | 02/27/2015
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Last Update Date | 04/19/2017
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Provider Practice Location Address
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Address Line | 7524 CYPRESS GARDENS BLVD
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City | WINTER HAVEN
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State | FL
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Zip | 33884-3200
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Country | US
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Telephone | 850-624-5666
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Fax | 321-348-5777
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Provider Business Mailing Address
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Address Line | 7524 CYPRESS GARDENS BLVD
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City | WINTER HAVEN
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State | FL
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Zip | 33884-3200
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Country | US
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Telephone | 850-624-5666
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Fax | 321-348-5777
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | THOMAS BROWN
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Credential | M.D
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Telephone | 850-624-5666
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | ME62144
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License Number State | FL
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